Physiotherapy 114 (2022) 47–53

Expert article

Physiotherapy-assisted prone or modified prone positioning in

ward-based patients with COVID-19: a retrospective cohort
study
Claudia Tatlow a,∗ , Sophie Heywood a , Carol Hodgson b,c , Georgina Cunningham d
, Matthew Conron e , Hui Yi Ng d , Harry Georgiou e , Gemma Pound a,c
a St Vincent’s Hospital Melbourne, Physiotherapy Department, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia
b The Alfred Hospital, Physiotherapy Department, 55 Commercial Rd, Melbourne 3004, Victoria, Australia
c Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine,

Monash University, Victoria, Australia

d St Vincent’s Hospital Melbourne, Department of General Medicine, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia
e St Vincent’s Hospital Melbourne, Department of Respiratory Medicine and Specialty Services, 41 Victoria Parade, Fitzroy 3065,

Victoria, Australia

Abstract
Objectives To evaluate short-term change in oxygenation and feasibility of physiotherapy-assisted prone or modified prone positioning in
awake, ward-based patients with COVID-19.
Design Retrospective observational cohort study.
Setting General wards, single-centre tertiary hospital in Australia.
Participants Patients were included if ≥18 years, had COVID-19, required FiO2 ≥ 0.28 or oxygen flow rate ≥4 l/minute and consented to
positioning. Main outcome measures: Feasibility measures included barriers to therapy, assistance required, and comfort. Short-term change
in oxygenation (SpO2 ) and oxygen requirements before and 15 minutes after positioning.
Results Thirteen patients, mean age 75 (SD 14) years; median Clinical Frailty Scale score 6 (IQR 4 to 7) participated in 32 sessions of prone
or modified prone positioning from a total of 125 ward-based patients admitted with COVID-19 who received physiotherapy intervention.
Nine of thirteen patients (69%) required physiotherapy assistance and modified positions were utilised in 8/13 (62%). SpO2 increased in
27/32 sessions, with a mean increase from 90% (SD 5) pre-positioning to 94% (SD 4) (mean difference 4%; 95%CI 3 to 5%) after 15 minutes.
Oxygen requirement decreased in 14/32 sessions, with a mean pre-positioning requirement of 8 l/minute (SD 4) to 7 l/minute (SD 4) (mean
difference 2 l/minute; 95%CI 1 to 3 l/minute) after 15 minutes. In three sessions oxygen desaturation and discomfort occurred but resolved
immediately by returning supine.
Conclusion Physiotherapy-assisted prone or modified prone positioning may be a feasible option leading to short-term improvements in
oxygenation in awake, ward-based patients with hypoxemia due to COVID-19. Further research exploring longerterm health outcomes and
safety is required.

Keywords: COVID-19; Physical therapy modalities; Prone positioning; Acute respiratory failure

∗ Corresponding author.
E-mail addresses: claudia.tatlow@gmail.com (C. Tatlow), sophie.heywood@svha.org.au (S. Heywood), carol.hodgson@monash.edu
(C. Hodgson), georgina.cunningham@svha.org.au (G. Cunningham), Matthew.CONRON@svha.org.au (M. Conron), huiyi.ng@svha.org.au (H.Y. Ng),
harry.georgiou@svha.org.au (H. Georgiou), gemma.pound@svha.org.au (G. Pound).

https://doi.org/10.1016/j.physio.2021.09.001
0031-9406/Crown Copyright © 2021 Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. All rights reserved.
48 C. Tatlow et al. / Physiotherapy 114 (2022) 47–53

Contribution of the Paper

• Prone positioning may offer a therapeutic option for awake, ward-based patients with hypoxemic respiratory failure due to COVID-19
• Physiotherapy assistance and use of modified prone positions may enable patients with high clinical frailty scale scores and full prone
limitations, such as obesity, to engage in prone positioning
• Prone or modified prone positioning leads to short-term improvements in oxygen saturation and reduced oxygen requirements, although
further studies are required to determine longer term effects and safety in ward-based settings
Crown Copyright © 2021 Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. All rights reserved.

Introduction with COVID-19 it may provide a further treatment option

Severe acute respiratory syndrome coronavirus (SARS-
CoV-2) emerged in early 2019 and is a multifactorial lung
process, with early viral pneumonitis, potentially evolving
to overt acute respiratory distress syndrome (ARDS) [1].
There is also mounting evidence that patients experience a
concurrent microvascular angiopathy and are at high risk of
larger vessel pulmonary thrombosis [2]. The resulting com-
bination of pulmonary parenchymal and vascular impairment
results in significant ventilation/perfusion mismatch and dis-
proportionate hypoxaemia [3]. Prone positioning is a valuable
strategy to counteract this physiologic impairment by achiev-
ing a more homogeneous distribution of ventilation, reducing
shunt fraction and optimising ventilation perfusion match-
ing [4]. Side-lying positions may be also associated with
beneficial effects on gas exchange in awake patients with
COVID-19 [5].
Despite there being limited and low-quality evidence,
there is growing interest in the use of prone positioning
in patients with COVID-19 outside intensive care settings
[6]. Guidelines have been developed for the use of prone
positioning in awake, non-intubated patients [7,8] based on
the success of prone positioning in mechanically ventilated
patients with COVID-19 and those with non-COVID-19
related acute respiratory distress syndrome (ARDS) [9].
Prone positioning is associated with improvements in oxy-
genation in ward based settings, however, only a minority of
studies have been conducted on patients with low respiratory
support requirements [10]. Exploring the use of prone posi-
tioning in patients with low respiratory support requirements
may offer further treatment options for individuals managed
in ward-based settings where intensive care admission or high
levels of respiratory support, such as non-invasive ventilation
(NIV) or continuous positive airway pressure (CPAP) are not
appropriate due to limits of care.
External to intensive care settings, clinician input is critical
to ensure prone positioning is safe and successful [11]. Phys-
iotherapists have the skills and knowledge to explore assisted
and modified prone positioning, based on physiological prin-
ciples and patients’ functional ability, whilst also managing
risks [12]. Physiotherapy-assisted prone and modified prone
positioning is evolving in clinical practice [8] and although
it has not been specifically evaluated in ward-based patients
for patients with functional limitations. Furthermore, previ-
ous studies exploring awake prone positioning have generally
not considered a modified prone position for patients unable
to achieve a full prone position.
The objective of this study is to evaluate the short-term
change in oxygenation and feasibility of physiotherapy-
assisted prone or modified prone positioning in awake
patients with COVID-19, managed in a ward-based setting
of a tertiary teaching hospital in Melbourne, Australia.
Methods
Study design and setting
A retrospective cohort study was conducted at St Vincent’s
Hospital Melbourne (SVHM) and included patients diag-
nosed with COVID-19 between July and September 2020.
This time period included the surge of COVID-19 patient
admissions in this Melbourne-based hospital. During the
time of the study, admissions included many people from
residential aged care facilities (RACF) who had tested pos-
itive to COVID-19 and were transferred to hospital related
to government directives regardless of their requirement for
medical intervention or respiratory support. The study was
approved by the institutional ethics review committee, includ-
ing a waiver of consent for data collection and use. The study
was reported according to the STROBE guidelines [13].
Patients included were in a general ward setting and were
agreeable to physiotherapy-assisted prone or modified prone
positioning. Patients in this study were managed on the
SVHM general wards due to having low respiratory sup-
port requirements or because they were deemed inappropriate
for intensive care as per their Acute Resuscitation Plan. The
maximum oxygen requirement able to be delivered in this set-
ting was high-flow oxygen therapy up to 40 l/minute, with a
FiO2 of 0.50. The treating medical team documented oxygen
saturation targets for each patient.
Suitability and decision making around which patients
were appropriate and would potentially benefit from prone
positioning was based on established algorithms (Appendix
A and B). Awake prone positioning was offered as a treat-
ment option if patients were hypoxic, requiring a FiO2 ≥ 0.28
 C. Tatlow et al. / Physiotherapy 114 (2022) 47–53
or oxygen flow rates of ≥4 l/minute to achieve target oxygen
saturations [7]; had capacity to consent to therapy, accept-
ing prone positioning as part of their treatment; and were not
deemed for end of life care as per the medical team. Patients
were excluded if they had an altered mental state impeding
their ability to understand and participate in the treatment.
A standardised approach was undertaken when prone
positioning was attempted. There was no pre-oxygenation
provided prior to positioning. The treating physiotherapist/s
took a SpO2 measurement before assisting the patient into a
prone or modified prone position (Appendix C).
Prone – patients lay on their front with their head turned
to one side and both arms tucked under the chest/shoulders
or positioned above their head.
Three quarter (3/4) prone – patients lay towards their
front with pillow support beneath their body and head turned
to one side.
Side lie – patients lay on their side with a pillow in front
/ beneath their trunk and another between their knees for
support.
All vital signs were monitored throughout the duration
of the physiotherapy positioning treatment and prone posi-
tioning was ceased if any measurements reached clinical
review criteria on the adult observation and response chart
(heart rate >100; SpO2 <the documented target oxygen sat-
urations, systolic blood pressure >180 or <90, respiratory
rate >25). Appropriate placement of padding and pillows
to pressure points, such as the shoulders, pelvis, knees and
ankles, was used throughout to increase comfort and reduce
the risk of pressure injuries. After obtaining a suitable posi-
tion, the treating physiotherapist asked the patient if they
were comfortable and amenable to remain in the position.
For safety purposes all patients were monitored by the phys-
iotherapist for a minimum of 15 minutes following position
change. After being in the position for 15-minutes, a SpO2
measurement was taken. If deemed stable and the patient
was comfortable and agreeable, patients stayed in the posi-
tion and were monitored by nursing staff. Nursing staff had a
1:4 nurse to patient ratio and could notify the physiotherapist
if they desaturated or required assistance to return the patient
to their usual supine position. Nursing staff did not participate
in data collection, meaning reliable data on the duration of the
intervention was unavailable. Routine nursing care included
regular repositioning for pressure care however this differs
from therapeutic positioning to optimise respiratory func-
tion. The treating physiotherapists entered their notes into
the patient’s electronic medical record as per usual clinical
practice.
Patient selection
The medical records of all COVID-19 ward admissions
were screened between 19th July–23rd September 2020.
Patients were included in the study if they were of adult
age (≥18 years), had a confirmed diagnosis of COVID-
19 by nasopharyngeal RT-PCR; and required a FiO2 ≥
49
0.28 or oxygen flow rate of ≥4 l/minute to achieve doc-
umented target oxygen saturation levels. Those patients
included in the study consented to assisted prone or modified
prone positioning as part of their physiotherapy treatment
(Fig. 1).
Data collection and management
Investigators (CT, SH) retrospectively screened the elec-
tronic medical records of all patients admitted to the medical
wards at SVHM with COVID-19 and independently extracted
relevant data on all individuals who received physiotherapy-
assisted prone or modified prone positioning. The relevant
data was extracted in a de-identified form into an excel
spreadsheet. All data was stored in password protected elec-
tronic documents on secure organisational drives with access
only by study personnel.
Patient demographic data and baseline clinical charac-
teristics included age, gender, Charlson Comorbidity Index
(CCI) score [14], Clinical Frailty Scale score [15], smoking
history, usual place of residence, premorbid independence
with activities of daily living (ADLs) and premorbid mobility
(PMM) status. Clinical data consisted of length of hospital
stay, acute ward and ICU stay, treatment limitation orders,
resuscitation orders, and medical treatment. Survival and dis-
charge disposition were also recorded.
Outcomes
Outcomes of interest relating to feasibility and short-term
change in oxygenation were based on similar studies in awake
patients using prone positioning [16–18]. Feasibility mea-
sures such as the success rate in achieving prone or modified
prone positions, physiotherapy staffing requirements, and
recognition of barriers to therapy and patient comfort from
subjective reporting, were identified. Short-term change in
oxygenation was measured by changes in oxygen saturations
(SpO2 measured using pulse oximetry) and changes in oxy-
gen requirements (litres of oxygen (l/minute)) before and
15 minutes after prone or modified prone positioning. Any
transient oxygen desaturation, oxygen or intravenous tub-
ing displacement during the physiotherapy session were also
recorded.
Statistical analysis
Descriptive and categorical data was summarised in fre-
quency tables, presenting the subject counts and percentages.
Continuous data was summarised using mean (standard devi-
ation (SD)) or median (interquartile range (IQR)) figures,
depending on the underlying distribution of data. Univari-
ate analyses were performed, using chi-square or Fisher’s
exact test for categorical variables and Mann–Whitney
‘U’ test or independent samples t-test as appropriate for
continuous variables. Comparison of the mean (IQR) oxy-
gen saturations (SpO2 ) and oxygen requirements (l/minute)
50 C. Tatlow et al. / Physiotherapy 114 (2022) 47–53
Fig. 1. Selection of patients appropriate for physiotherapy assisted, prone or modified prone positioning.
immediately before and 15 minute after prone positioning
was completed using the paired samples t-test. Analyses were
conducted using SPSS version 24 (IBM SPSS Inc, Armonk,
NY).
Results
During the study period, 148 patients with COVID-19
were admitted to general wards, 125 of these patients received
physiotherapy intervention and 13 patients fulfilled the inclu-
sion criteria and consented to prone or modified prone
positioning as part of this intervention (Fig. 1). Demographic
data and clinical characteristics are summarised in Table 1.
Mean age of the patient cohort was 75 (SD 14) years, median
Charlson Comorbidity Index was 6 (IQR 3 to 8), median
Clinical Frailty Scale score was 6 (IQR 4 to 7) and 5/13
(39%) patients lived in supported accommodation or a RACF.
The median hospital length of stay (LOS) on the acute ward
was 14 (IQR 10 to 17.5) days and 10/13 (77%) patients had
treatment limitation orders in place.
Feasibility
During the study period, a total of 32 physiotherapy-
assisted, prone or modified prone positioning sessions were
completed on 13 patients, with a median of 1.5 (IQR 1 to
4) sessions per patient. Four of the 13 (31%) patients were
able to independently obtain a prone position, 3/13 (23%)
patients required the assistance of one physiotherapist and
6/13 (46%) patients required the assistance of two physio-
therapists. A full prone position was tolerated in all sessions
for 5/13 (39%) patients and in three out of four sessions for
one patient (8%). A modified prone position was used with
8/13 (62%) patients in 15/32 (47%) sessions. Of the sessions
when a modified position was required, three-quarter prone
was used in 3/15 (20%) sessions and side-lie in 12/15 (80%)
sessions. Obesity was the most common reason (in 4/8 (50%)
patients) why a decision was made to use a modified prone
position to improve patient comfort. The only other reason
for use of a modified position instead of full prone was due to
the post-operative orders for a patient who had recently had
neck surgery. Four (31%) patients reported musculoskeletal
 C. Tatlow et al. / Physiotherapy 114 (2022) 47–53 51

Table 1
Demographic and clinical details of the cohort.
Variable (unit) Cohort (n = 13) Survivors (n = 6) Non-survivors (n = 7)
Age (Years), mean (SD) 75 (14) 67 (16) 82 (7)
Male gender, n (%) 9 (69) 4 (67) 5 (71)
Preferred language, n (%)
- English 9 (69) 5 (83) 4 (57)
-NESL 4 (31) 1 (17) 3 (43)
Charlson comorbidity index (CCI) score, median (IQR) 6 (3 to 8) 3 (1 to 6) 6 (6-8)
Clinical Frailty Score, median (IQR) 6 (3 to 7) 3 (2 to 5) 7 (6 to 7)
Smoking history, n (%)
- Current 1 (8) 1 (17) 0 (0)
- Past 7 (54) 2 (33) 5 (71)
- Never 5 (39) 3 (50) 2 (29)
Usual place of residence, n (%)
- Home 8 (62) 4 (67) 4 (57)
- Supported accommodation 3 (23) 1 (17) 2 (29)
- Nursing home 2 (15) 1 (17) 1 (14)
Activities of daily living (ADLs), n (%)
- Independent 6 (46) 5 (83) 1 (14)
- Requires assistance 7 (54) 1 (17) 6 (86)
Premorbid mobility (PMM), n (%)
- Independent 8 (62) 6 (100) 2 (29)
- Supervision 3 (23) 0 (0) 3 (43)
- 1x assist 2 (15) 0 (0) 2 (29)
Hospital LOS (days), median (IQR) 15 (11 to 18) 20 (12 to 26) 11 (11 to 16)
LOS on the acute ward (days), median (IQR) 14 (10 to 18) 20 (10 to 26) 11 (11 to 16)
LOS in ICU (days), median (IQR) 2 (1 to 2) 2 (1 to 2) 0 (0-0)
ICU admission, n (%)
- Yes 2 (15) 2 (33) 0 (0)
- No 11 (85) 4 (67) 7 (100)
Treatment limitation orders, n (%)
- Not for escalation beyond ward-based care 10 (77) 3 (50) 7 (100)
- No limitations to escalation beyond ward-based care 3 (23) 3 (50) 0 (0)
Resuscitation orders, n (%)
- Not for resuscitation 10 (77) 3 (50) 7 (100)
- For resuscitation 3 (23) 3 (50) 0 (0)
Medical treatment, n (%)
- Antibiotic and corticosteroid agents 7 (54) 1 (17) 6 (86)
- Antibiotic, corticosteroid and antiviral agents 6 (46) 5 (83) 1 (14)
n = number, IQR = interquartile range, NESL = non english speaking language, LOS = length of stay.

pain which limited their ability to remain in a prone or mod-
ified prone position. The mean age of patients’ who reported
musculoskeletal pain was 85 (SD 6) years.
Short-term change in oxygenation
Across 32 sessions, SpO2 increased after 15-minutes in
prone or modified prone in 27/32 (84%) sessions, 1–3% in
9/27 (33%) sessions and >4% in 18/27 (67%) sessions. SpO2
was unchanged in 3/32 (9%) sessions and reduced in 2/32
(6%) sessions by 3% (Fig. 2 and supplementary material).
The mean SpO2 increased from 90% (SD 5) pre-positioning
to 94% (SD 4) (mean difference 4%; 95% CI 3 to 5%)
after 15 minutes of positioning. Across 32 sessions, oxy-
gen requirement decreased in 14/32 (44%) sessions and was
unchanged in 18/32 (56%) sessions. The mean oxygen usage
prior to prone or modified prone positioning was 8 l/minute
(SD 4) vs 7 l/minute (SD 4) (mean difference 2 l/minute; 95%
CI 1 to 3 l/minute) after 15 minutes of positioning. Three
patients during seven sessions were able to wean from a non-
rebreather or Hudson mask to nasal prongs. Two patients,
during one session each, were on high flow oxygen therapy
via an AIRVO machine and experienced no change in oxy-
gen requirement before or 15 minutes after initiating prone
positioning.
There were 3/32 sessions in which physiotherapy care
was modified due to a patient’s negative response to posi-
tioning. For one patient, the only session they completed
was limited to 15 minutes due to self-reported discomfort
and observed increased work of breathing that resolved with
supine repositioning. Another patient had 2/4 sessions limited
to 90 minutes and 25 minutes due to drop in oxygen satura-
tion of 3% during each session which resolved with supine
repositioning.
52 C. Tatlow et al. / Physiotherapy 114 (2022) 47–53
Fig. 2. Scatter plot for changes in oxygenation after 15-minutes in prone
or modified prone positioning across all 32 physiotherapy sessions (for
scatter plots for individual participant results please see the Supplementary
material).
Discharge
Six out of 13 (46%) patients survived to hospital discharge
with 3 (50%) being discharged to their usual residence and 3
(50%) being transferred to a subacute facility. Seven (54%)
patients did not survive hospital admission, these patients
were more likely to be frail and require assistance with pre-
morbid ADLs and mobility.
Discussion
This retrospective observational study described the
feasibility and short-term change in oxygenation of
physiotherapy-assisted prone or modified prone positioning
in awake, ward-based patients with COVID-19.
The cohort of patients had a high mortality rate, which
was expected given their age, comorbidities, level of frailty
and limits of care. A major concern throughout the study
was that prone positioning in acutely unwell, frail patients
could have resulted in discomfort or distress with little known
benefit to the patients. Frail individuals with critical illness
are likely to have poorer outcomes and a higher mortality rate
[19] but may still have enough intrinsic capacity to endure
the stressors of hospitalisation and make a good recovery
[20]. Therefore clinicians are encouraged to empathetically
focus on engaging with and supporting frail patients to ensure
access to care in keeping with their values and goals [21].
The multidisciplinary team tried several approaches to help
manage the deteriorating respiratory status of these patients in
the ward-setting. This study evaluated an option for therapy
that physiotherapists could consider for frail patients, if it
were in keeping with their values and goals [21,22]. While
the benefits of prone positioning remain unclear from this
study, patients who are able to give consent could be offered
prone positioning as a treatment option until future research
can be undertaken to further inform the team and the patient
of the risks or benefits.
Previous published studies have largely excluded patients
who were unable to independently obtain a prone position,
subsequently having younger, less frail and more function-
ally independent patient participants [10]. A strength of this
study was that patients who were unable to self-prone were
included. Furthermore, when a full prone position was not
possible, most commonly due to obesity, modified positions
were used. This finding is clinically relevant due to the
prevalence of obesity and its role as a risk factor for those
patients with COVID-19 in developing severe disease [23].
Full prone positioning was only used in five of the 32 physio-
therapy sessions highlighting the need for ongoing evaluation
in the clinical effect of modified positions. Positioning was
achieved with only a minority of patients experiencing dis-
comfort or oxygen desaturation, which resolved with return
to a supine position.
Patients demonstrated an improvement in short-term oxy-
gen saturations and a reduction in oxygen requirements when
in the prone or modified prone position. The mean improve-
ment in oxygen saturation is similar to findings of previous
studies using awake prone positioning, including a meta-
analysis of twenty-five studies that showed a mean difference
in SpO2 of 4.75% (95% CI 3 to 6%) [10]. Although it may
be unclear how clinically significant small changes in oxy-
genation are for individual patient outcomes, the reduction in
oxygen requirements observed in this study holds additional
clinical significance. Three patients during seven sessions
were able to wean from an oxygen therapy mask to nasal
prongs. As a result, patients may have experienced the addi-
tional benefits of enhanced communication and improved
comfort [24].
This study has a number of limitations. It used a small
cohort of participants, limiting the power and generalisability
of the results. Only thirteen patients met our criteria for prone
positioning as majority of patients were admitted to hospital
from RACF due to inadequate resources to manage COVID-
19, regardless of the severity of illness. This resulted in a
large number of patients who did not require medical inter-
ventions or respiratory support for symptoms of COVID-19,
but rather for isolation from other residents or for mobility
input. The retrospective design limited the data available for
interpretation, such as the length of time patients tolerated
prone positions or body mass index measures, as well as the
impact of confounding variables. It is also acknowledged that
one of the authors was a treating physiotherapist in the study
which may have introduced a source of observer bias.
Nonetheless, this is essentially a proof of concept study,
aimed at describing the experience of using prone posi-
tioning in generally frail, awake, ward-based patients. It
is acknowledged that in situations with increased clinical
demand or workforce shortages, the feasibility of providing
physiotherapy-assisted prone positioning will be impacted.
Larger prospective studies are required to better elucidate the
longer-term clinical benefits.
 C. Tatlow et al. / Physiotherapy 114 (2022) 47–53
Conclusions
Prone or modified prone positioning may be a feasible
therapeutic option for short-term improvements in oxygena-
tion for patients with hypoxemic respiratory failure due to
COVID-19 depending on available resources. This small ret-
rospective observational study should be interpreted with
caution and any changes in clinical practice requires evidence
of safety and longer term improvements in health outcomes.
Ethical approval: St Vincent’s Hospital Human Research
Ethics Committee approved this study (LRR 218/20).
Funding: This was an unfunded investigator initiated study.
CH is supported by a NHMRC Investigator Grant and a Heart
Foundation Fellowship.
Conflicts of interest: None declared.
Appendix A. Supplementary data
Supplementary material related to this article can be
found, in the online version, at doi:https://doi.org/10.1016/
j.physio.2021.09.001.
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